1. Nama Anak Didik :........................................................................
a. Nama Lengkap :........................................................................ b. Nama Panggilan :........................................................................ 2. Tempat dan Tanggal Lahir :........................................................................ 3. Jenis Kelamin :........................................................................ 4. Agama :........................................................................ 5. Anak Ke :........................................................................ 6. Nama Orang Tua/Wali :........................................................................ 7. Pekerjaan Orang Tua/Wali :........................................................................ a. Ayah :........................................................................ b. Ibu :........................................................................ 8. Alamat Orang Tua/Wali :........................................................................ a. Jalan :........................................................................ b. Desa/Keluarahan :........................................................................ c. Kecamatan :........................................................................ d. Kabupaten/Kota :........................................................................ e. Provinsi :........................................................................ 9. Diterima di RA :........................................................................